Association of organizational culture and climate with variation in the clinical outcomes of collaborative care for maternal depression in community health centers.

Background: Organizational factors may help explain variation in the effectiveness of evidence-based clinical innovations through implementation and sustainment. This study tested the relationship between organizational culture and climate and variation in clinical outcomes of the Collaborative Care Model (CoCM) for treatment of maternal depression implemented in community health centers. Method: Organizational cultures and climates of 10 community health centers providing CoCM for depression among low-income women pregnant or parenting were assessed using the organizational social context (OSC) measure. Three-level hierarchical linear models tested whether variation in culture and climate predicted variation in improvement in depression symptoms from baseline to 6.5-month post-baseline for N = 468 women with care ±1 year of OSC assessment. Depression symptomology was measured using the Patient Health Questionnaire (PHQ-9). Results: After controlling for patient characteristics, case mix, center size, and implementation support, patients served by centers with more proficient cultures improved significantly more from baseline to 6.5-month post-baseline than patients in centers with less proficient cultures (mean improvement = 5.08 vs. 0.14, respectively, p = .020), resulting in a large adjusted effect size of dadj = 0.78. A similar effect was observed for patients served by centers with more functional climates (mean improvement = 5.25 vs. 1.12, p < .044, dadj = 0.65). Growth models indicated that patients from all centers recovered on average after 4 months of care. However, those with more proficient cultures remained stabilized whereas patients served by centers with less proficient cultures deteriorated by 6.5-month post-baseline. A similar pattern was observed for functional climate. Conclusions: Variation in clinical outcomes for women from historically underserved populations receiving Collaborative Care for maternal depression was associated with the organizational cultures and climates of community health centers. Implementation strategies targeting culture and climate may improve the implementation and effectiveness of integrated behavioral health care for depression.

While many implementation theories espouse the importance of organizational culture and climate for the successful implementation of evidence-based practices in primary care, there is little research that tests this hypothesis. Since there are interventions which can improve organizational culture and climate, having more evidence that these factors are associated with implementation would support efforts to modify these aspects of a community health center as a means of improving implementation. This study showed that the extent to which patients clinically benefitted from the evidence-based Collaborative Care Model for maternal depression was related to the prevailing culture and climate of community health centers where they received treatment. Specifically, women seen at centers in which the staff and providers indicated that their organizations prioritize responsiveness to patients' needs over competing organizational goals and maintain competence in up-to-date treatment models (referred to as proficient culture), and understand their role in the organization and receive the cooperation and support they need from colleagues and supervisors to perform their job well (functional climate) were associated with sustained improvements in depression symptoms. This benefit was independent of other factors already known to be associated with these outcomes. Implementation strategies that target organizational culture (i.e., priorities and expectations for staff) and climate (i.e., quality of working environment) may improve the clinical outcomes of integrated collaborative care models for depression and reduce the commonly seen variation in outcomes across health centers.

Screening for parent and child ADHD in urban pediatric primary care: pilot implementation and stakeholder perspectives.

BACKGROUND: ADHD commonly co-occurs in children and parents. When ADHD is untreated in parents, it contributes to negative child developmental and treatment outcomes. Screening for parent and child ADHD co-occurrence in pediatric primary care may be an effective strategy for early identification and treatment. There is no data on whether this screening model can be implemented successfully and there exists limited guidance on how to effectively approach parents about their own ADHD in pediatric settings. Even greater sensitivity may be required when engaging with families living in urban, low SES communities due to systemic inequities, mistrust, and stigma. METHODS: The current pilot study described the first 6 months of implementation of a parent and child ADHD screening protocol in urban pediatric primary care clinics serving a large population of families insured through Medicaid. Parents and children were screened for ADHD symptoms at annual well-child visits in pediatric primary care clinics as part of standard behavioral health screening. Independent stakeholder group meetings were held to gather feedback on factors influencing the implementation of the screening and treatment strategies. Mixed methods were used to examine initial screening completion rates and stakeholder perspectives (i.e., parents, primary care office staff, pediatricians, and behavioral health providers) on challenges of implementing the screening protocol within urban pediatric primary care. RESULTS: Screening completion rates were low (19.28%) during the initial 6-month implementation period. Thematic analysis of stakeholder meetings provided elaboration on the low screening completion rates. Identified themes included: 1) divergence between provider enthusiasm and parent hesitation; 2) parent preference versus logistic reality of providers; 3) centering the experiences of people with marginalized identities; and 4) sensitivity when discussing parent mental health and medication. CONCLUSIONS: Findings highlight the importance of developing flexible approaches to screening parent and child ADHD in urban pediatric health settings and emphasize the importance of cultural sensitivity when working with marginalized and under-resourced families. TRIAL REGISTRATION: NCT04240756 (27/01/2020).

Patient Perspectives Regarding Clinician Communication During Telemedicine Compared With In-Clinic Abortion.

OBJECTIVE: To explore patient perspectives regarding patient-clinician communication during telemedicine medication abortion compared with traditional, facility based, in-clinic visits. METHODS: We conducted semi-structured interviews with participants who received either live, face-to-face telemedicine or in-clinic medication abortion from a large, reproductive health care facility in Washington State. Using Miller's conceptual framework for patient-doctor communication in telemedicine settings, we developed questions exploring participants' experiences of the medication abortion consultation, including the clinician's verbal and nonverbal interpersonal approach and communication of relevant medical information, and the setting where care was received. We used inductive-deductive constant comparative analysis to identify major themes. We summarize patient perspectives using patient-clinician communication terms outlined in Dennis' quality abortion care indicator list. RESULTS: Thirty participants completed interviews (aged 20-38 years), 20 of whom had medication abortion by telemedicine and 10 who received in-clinic services. Participants who received telemedicine abortion services reported high-quality patient-clinician communication, which came from their freedom to choose their consultation location, and reported feeling more relaxed during clinical encounters. In contrast, most in-clinic participants portrayed their consultations as lengthy, chaotic, and lacking comfort. In all other domains, both telemedicine and in-clinic participants reported similar levels of interpersonal connection to their clinicians. Both groups appreciated medical information about how to take the abortion pills and relied heavily on clinic-based printed materials and independent online resources to answer questions during the at-home termination process. Both telemedicine and in-clinic participant groups were highly satisfied with their care. CONCLUSION: Patient-centered communication skills used by clinicians during facility based, in-clinic care translated well to the telemedicine setting. However, we found that patients who received medication abortion through telemedicine favorably ranked their patient-clinician communication overall as compared with those in traditional, in-clinic settings. In this way, telemedicine abortion appears to be a beneficial patient-centered approach to this critical reproductive health service.

Advance provision of medication for induced abortion: A qualitative study of patient perspectives.

OBJECTIVES: To examine potential users' perspectives regarding the provision of abortion medications for future use or "advance provision." STUDY DESIGN: In this qualitative study, we partnered with an independent reproductive health care clinic in Washington State to conduct semistructured, in-depth interviews with 22 individuals who obtained a medication abortion between August 2021 and January 2022. We asked participants their views on advance provision of abortion medications. Interviews were transcribed and deidentified. Inductive content analysis was used to identify major themes. RESULTS: Participants in our sample generally reacted positively to the idea of abortion medications for future use. Having pills in advance could improve timeliness and convenience of care and decrease the stigma associated with their use. Participants stressed the importance of adequate information regarding medication use, what to expect, and potential side effects. Most concerns about advance provision related to the safety and efficacy of medication abortion. CONCLUSIONS: This study found that individuals who recently obtained a medication abortion supported the provision of abortion medications for future use. IMPLICATIONS: Patient-centered educational materials, with adequate information for self-managing pregnancy termination, can be shared at time of prescription. Clinicians have an opportunity to offer these safe and effective medications in advance of need and increase timely access to this essential health care service. User concerns regarding abortion medications for future use should inform clinical innovation and evaluative research of service options.

Technique of intraoperative ultrasound-guided excision of impalpable breast lesions.

The introduction of breast screening programs has led to the increased detection of occult breast lesions requiring diagnostic surgical biopsy or breast-conserving surgery for early-stage breast cancer. Excision of impalpable breast lesions can be challenging. Whilst a variety of techniques have now been described including the use of adjuncts such as hook wires, radioactive seeds, magnetic seeds or radiofrequency devices, many of these modalities are expensive and can be logistically problematic. The technique of surgeon-performed ultrasound-guided excision is a straightforward technique which is safe, cost-efficient and avoids a painful preoperative procedure for patients such as hook wire localisation. Whilst the use of intraoperative ultrasound-guided excision of breast lesions has been widely reported, the actual technique itself has been less well described.

In vivo assignment of methylmalonic acid in breast tissue using 2D MRS and relationship with breast density, menopausal status and cancer risk.

BACKGROUND: Methylmalonic acid (MMA) is linked to progression and aggressiveness of tumours. A recent study showed that high levels of circulatory MMA directed genetic programs promoting cancer progression. PURPOSE: To evaluate in vivo two-dimensional correlated spectroscopy (2D COSY) data from women at elevated risk of breast cancer to determine if resonances consistent with MMA are present, and if so to correlate levels with breast density, menopausal status and risk categories. MATERIALS AND METHODS: With institutional review board approval, 106 women at elevated risk (mean age 47), including 46 participants at medium risk, 43 at high risk with no known mutation and 17 BRCA-mutation carriers, were recruited. Breast density was assessed using a T2 sequence. A T1 sequence was used to place the voxel for the 2D COSY data. Peak volumes were normalized to the methylene peak at (1.30, 1.30) ppm. Chi-squared and Mann-Whitney tests were used. RESULTS: Two resonances are assigned on the diagonal at 3.15 ppm and 3.19 ppm consistent with and denoted MMA1 and MMA2 respectively. MMA1 and MMA2 increased in parallel with increased risk. BRCA-mutation carriers recorded an increase in mean MMA1 of 120% (p = 0.033) and MMA2 of 127% (p = 0.020) in comparison with participants with no known mutation. BRCA-mutation carriers with dense breasts recorded a significant increase in mean MMA1 of 137% (p = 0.002) and in mean MMA2 of 143% (p = 0.004) compared with BRCA-mutation participants with low-density breast tissue. MMA1 and MMA2 were higher in premenopausal women with dense breasts compared with those with low-density tissue. The highest values of MMA were recorded in BRCA-mutation carriers. CONCLUSION: Two tentative assignments are made for MMA in breast tissue of women at elevated risk for cancer. BRCA-mutation carriers exhibited higher values of MMA than those with no known mutation. Premenopausal women with BRCA mutation and dense breasts recorded the highest levels of MMA compared with other categories.

Perinatal Depressive Symptoms and Viral Non-suppression Among a Prospective Cohort of Pregnant Women Living with HIV in Nigeria, Kenya, Uganda, and Tanzania.

Depression is common during pregnancy and is associated with reduced adherence to HIV-related care, though little is known about perinatal trajectories of depression and viral suppression among women living with HIV (WLHV) in sub-Saharan Africa. We sought to assess any association between perinatal depressive symptoms and viral non-suppression among WLWH. Depressive symptomatology and viral load data were collected every 6 months from WLWH enrolled in the African Cohort Study (AFRICOS; January 2013-February 2020). Generalized estimating equations modeled associations between depressive symptoms [Center for Epidemiological Studies Depression (CES-D) ≥ 16] and viral non-suppression. Of 1722 WLWH, 248 (14.4%) had at least one pregnancy (291 total) and for 61 pregnancies (21.0%), women reported depressive symptoms (13.4% pre-conception, 7.6% pregnancy, 5.5% one-year postpartum). Depressive symptomatology was associated with increased odds of viral non-suppression (aOR 2.2; 95% CI 1.2-4.0, p = 0.011). Identification and treatment of depression among women with HIV may improve HIV outcomes for mothers.

Remote Delivery in Reproductive Health Care: Operation of Direct-to-Patient Telehealth Medication Abortion Services in Diverse Settings.

PURPOSE: Established models of reproductive health service delivery were disrupted by the coronavirus disease 2019 (COVID-19) pandemic. This study examines rapid innovation of remote abortion service operations across health care settings and describes the use of telehealth consultations with medications delivered directly to patients. METHODS: We conducted semi-structured interviews with 21 clinical staff from 4 practice settings: family planning clinics, online medical services, and primary care practices-independent or within multispecialty health systems. Clinicians and administrators described their telehealth abortion services. Interviews were recorded, transcribed, and analyzed. Staff roles, policies, and procedures were compared across practice settings. RESULTS: Across all practice settings, telehealth abortion services consisted of 5 operational steps: patient engagement, care consultations, payment, medication dispensing, and follow-up communication. Online services and independent primary care practices used asynchronous methods to determine eligibility and complete consultations, resulting in more efficient services (2-5 minutes), while family planning and health system clinics used synchronous video encounters requiring 10-30 minutes of clinician time. Family planning and health system primary care clinics mailed medications from clinic stock or internal pharmacies, while independent primary care practices and online services often used mail-order pharmacies. Online services offered patients asynchronous follow-up; other practice settings scheduled synchronous appointments. CONCLUSIONS: Rapid innovations implemented in response to disrupted in-person reproductive health care included remote medication abortion services with telehealth assessment/follow-up and mailed medications. Though consistent operational steps were identified across health care settings, variation allowed for adaptation of services to individual sites. Understanding remote abortion service operations may facilitate dissemination of a range of patient-centered reproductive health services.Annals "Online First" article.

Effect of intervention delivered by frontline maternal care providers to improve outcome and parenting skills among adolescents with perinatal depression in Nigeria (the RAPiD study): A cluster randomized controlled trial.

BACKGROUND: Perinatal depression is more common and is associated with greater negative consequences among adolescents than adults. Psychosocial interventions designed for adults may be inadequate at addressing the unique features of adolescent perinatal depression. METHODS: In a two-arm parallel cluster randomized trial conducted in thirty primary maternal care clinics in Ibadan, Nigeria (15-intervention and 15-control) we compared age-appropriate intervention consisting of problem-solving therapy, behavioral activation, parenting skills training, and parenting support from a self-identified adult to care as usual. Pregnant adolescents (aged <20 years) at fetal gestational age16-36 weeks with moderate to severe depression were recruited. Primary outcomes were depression symptoms (Edinburgh Postnatal Depression Scale, EPDS) and parenting practices (Infant-Toddler version of the Home Inventory for Measurement of the Environment, HOME-IT) at six-months postnatal. RESULTS: There were 242 participants (intervention arm: 141; Control arm: 101), with a mean age of 18∙0 (SD-1∙2). Baseline mean EPDS score was 14∙2 (SD-2.1); 80∙1 % completed the six-month postnatal follow-up. The intervention group had lower level of depressive symptoms than the control group, mean EPDS scores: 5∙5 (SD-3∙6) versus 7∙2 (SD-4∙0) (adjusted mean difference -1∙84 (95%CI- 3∙06 to -0∙62; p = 0∙003) and better parenting practices, mean total HOME-IT scores: 29∙8 (SD-4∙4) versus 26∙4 (SD-4∙2) (adjusted mean difference 3∙4 (95%Cl- 2∙12 to 4∙69, p = 0∙001). LIMITATIONS: This study explored the effect of complex interventions making it difficult to know precisely what aspects produced the outcomes. CONCLUSIONS: An age-appropriate psychosocial intervention package holds promise for scaling up care for adolescents with perinatal depression especially in resource-constrained settings. TRIAL REGISTRATION: ISRCTN16775958. Registered on 30 April 2019.

Suicide and Maternal Mortality.

PURPOSE OF REVIEW: Suicide is a leading cause of death in the perinatal period (pregnancy and 1 year postpartum). We review recent findings on prevalence, risk factors, outcomes, and prevention and intervention for suicide during pregnancy and the first year postpartum. RECENT FINDINGS: Standardization of definitions and ascertainment of maternal deaths have improved identification of perinatal deaths by suicide and risk factors for perinatal suicide. Reports of a protective effect of pregnancy and postpartum on suicide risk may be inflated. Clinicians must be vigilant for risk of suicide among their perinatal patients, especially those with mental health diagnoses or prior suicide attempts. Pregnancy and the year postpartum are a time of increased access to healthcare for many, offering many opportunities to identify and intervene for suicide risk. Universal screening for suicide as part of assessment of depression and anxiety along with improved access to mental health treatments can reduce risk of perinatal suicide.

Baseline situational analysis in Bangladesh, Jordan, Paraguay, the Philippines, Ukraine, and Zimbabwe for the WHO Special Initiative for Mental Health: Universal Health Coverage for Mental Health.

INTRODUCTION: Mental, neurological and substance use conditions lead to tremendous suffering, yet globally access to effective care is limited. In line with the 13th General Programme of Work (GPW 13), in 2019 the World Health Organization (WHO) launched the WHO Special Initiative for Mental Health: Universal Health Coverage for Mental Health to advance mental health policies, advocacy, and human rights and to scale up access to quality and affordable care for people living with mental health conditions. Six countries were selected as 'early-adopter' countries for the WHO Special Initiative for Mental Health in the initial phase. Our objective was to rapidly and comprehensively assess the strength of mental health systems in each country with the goal of informing national priority-setting at the outset of the Initiative. METHODS: We used a modified version of the Program for Improving Mental Health Care (PRIME) situational analysis tool. We used a participatory process to document national demographic and population health characteristics; environmental, sociopolitical, and health-related threats; the status of mental health policies and plans; the prevalence of mental disorders and treatment coverage; and the availability of resources for mental health. RESULTS: Each country had distinct needs, though several common themes emerged. Most were dealing with crises with serious implications for population mental health. None had sufficient mental health services to meet their needs. All aimed to decentralize and deinstitutionalize mental health services, to integrate mental health care into primary health care, and to devote more financial and human resources to mental health systems. All cited insufficient and inequitably distributed specialist human resources for mental health as a major impediment. CONCLUSIONS: This rapid assessment facilitated priority-setting for mental health system strengthening by national stakeholders. Next steps include convening design workshops in each country and initiating monitoring and evaluation procedures.

Breast Tissue Chemistry Measured In Vivo In Healthy Women Correlate with Breast Density and Breast Cancer Risk.

BACKGROUND: The relationship of tissue chemistry to breast density and cancer risk has not been documented despite breast density being a known risk factor. PURPOSE: To investigate whether distinct chemical profiles associated with breast density and cancer risk are identified in healthy breast tissue using in vivo two-dimensional correlated spectroscopy (2D COSY). STUDY TYPE: Prospective. POPULATION: One-hundred-seven participants including 55 at low risk and 52 at high risk of developing breast cancer. FIELD STRENGTH/SEQUENCE: 3 T/ axial/ T1, T2, 2D COSY. ASSESSMENT: Two radiologists defined breast density on T2. Interobserver variability assessed. Peak volumes normalized to methylene at (1.30, 1.30) ppm as internal shift reference. STATISTICAL TESTS: Chi-squared/Mann-Whitney/Kappa statistics/Kruskal Wallis/pairwise analyses. Significance level 0.05. RESULTS: Ten percentage were fatty breasts, 39% scattered fibroglandular, 35% heterogeneously dense, and 16% extremely dense. Interobserver variability was excellent (kappa = 0.817). Sixty percentage (64/107) were premenopausal. Four distinct tissue chemistry categories were identified: low-density (LD)/premenopausal, high-density (HD)/premenopausal, LD/postmenopausal, and HD/postmenopausal. Compared to LD, HD breast chemistry showed significant increases of cholesterol (235%) and lipid unsaturation (33%). In the low-risk category, postmenopausal women with dense breasts recorded the largest significant changes including cholesterol methyl 540%, lipid unsaturation 207%, glutamine/glutamate 900%, and choline/phosphocholine 800%. In the high-risk cohort, premenopausal women with HD recorded a more active chemical profile with significant increases in choline/phosphocholine 1100%, taurine/glucose 550% and cholesterol sterol 250%. DATA CONCLUSION: Four distinct chemical profiles were identified in healthy breast tissue based on breast density and menopausal status in participants at low and high risk. Gradual increase in neutral lipid content and metabolites was noted in both risk groups across categories in different order. In low risk, the HD postmenopausal category exhibited the highest metabolic activity, while women at high risk exhibited the highest lipid content and metabolic activity in the HD premenopausal category. LEVEL OF EVIDENCE: 2 TECHNICAL EFFICACY STAGE: 3.

Care team and practice-level implementation strategies to optimize pediatric collaborative care: study protocol for a cluster-randomized hybrid type III trial.

BACKGROUND: Implementation facilitation is an effective strategy to support the implementation of evidence-based practices (EBPs), but our understanding of multilevel strategies and the mechanisms of change within the "black box" of implementation facilitation is limited. This implementation trial seeks to disentangle and evaluate the effects of facilitation strategies that separately target the care team and leadership levels on implementation of a collaborative care model in pediatric primary care. Strategies targeting the provider care team (TEAM) should engage team-level mechanisms, and strategies targeting leaders (LEAD) should engage organizational mechanisms. METHODS: We will conduct a hybrid type 3 effectiveness-implementation trial in a 2 × 2 factorial design to evaluate the main and interactive effects of TEAM and LEAD and test for mediation and moderation of effects. Twenty-four pediatric primary care practices will receive standard REP training to implement Doctor-Office Collaborative Care (DOCC) and then be randomized to (1) Standard REP only, (2) TEAM, (3) LEAD, or (4) TEAM + LEAD. Implementation outcomes are DOCC service delivery and change in practice-level care management competencies. Clinical outcomes are child symptom severity and quality of life. DISCUSSION: This statewide trial is one of the first to test the unique and synergistic effects of implementation strategies targeting care teams and practice leadership. It will advance our knowledge of effective care team and practice-level implementation strategies and mechanisms of change. Findings will support efforts to improve common child behavioral health conditions by optimizing scale-up and sustainment of CCMs in a pediatric patient-centered medical home. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04946253 . Registered June 30, 2021.

Can Family Medicine's Counterculture History Help Shape an Anti-Racist Future?

Family medicine prides itself on community engagement and has embraced its counterculture roots. After the racial and social reckoning of 2020, including the COVID-19 pandemic and the Black Lives Matters movement, family medicine, as a specialty, must embrace anti-racism as a core value to meet community needs. This article reflects on the foundational tenets of family medicine's origin. It highlights the current disparities regarding professional representation while offering equitable, intentional, and collaborative approaches to move toward and achieve anti-racism within the specialty, medical education, and the community.

Association of psychiatric consultant characteristics with clinical outcomes of collaborative care for depression.

Context: Adult depression treatment in primary care is improved by integrated behavioral health such as the Collaborative Care Model (CoCM) but outcomes vary across health centers. Objective: Identify CoCM team factors associated with variation in clinical outcomes. Study Design: Correlative study of survey with linked clinical data from routine care. Setting or Dataset: Primary care health centers in Washington state participating in two CoCM implementation and sustainment initiatives (MHIP and BHIP). Clinical data from the Care Management Tracking System (CMTS) used as part of routine clinical care in all sites. Population studied: CoCM clinical teams and adults diagnosed with depression and receiving care from 31 distinct clinic sites throughout Washington state. Instrument: A survey for CoCM Care Managers was developed based on qualitative work exploring CoCM team function in eight domains: overall team function (OTF), psychiatric consultant (PsyC), relationship with primary care physicians (RPCP), role in the practice (RP), training experience (TE), thoughts on CoCM (TOC), leadership support (LS), and overall experience with CoCM (EXP). Outcome Measures: Depression symptoms (PHQ-9) measured as part of regular clinical care. Clinically significant improvements were defined as ≥50% improvement, last PHQ-9 measured <10, and a last PHQ-9 measured <5 (remission). Results: Data from 59 Care Manager surveys and 2509 patients from 31 clinics showed psychometric evidence for the 8 survey domains. Unadjusted multilevel mixed-effects logistic regression found the PsyC domain was associated (p<0.05) with >50% change in PHQ-9 (OR=1.32, p=0.046), last PHQ-9 <10 (OR=1.34, p=0.009), and last PHQ-9 <5 (OR=1.25, p=0.029). Adjusting simultaneously for both clinic-level and patient-level variables, the PsyC domain was significantly associated with likelihood of patient remission (last PHQ-9 <5; OR=1.22, p=0.031). Conclusions: An instrument to assess perceived functioning of the CoCM team had psychometric support. Perceived characteristics of psychiatric consultants was associated with likelihood of depression remission. Characteristics included interest in teaching, commitment to the site, making efforts to have weekly meetings, and willingness to assist care managers on adjustment of treatment strategies. This study is the first to quantify variation in CoCM team functioning with patient outcomes and can be used to inform training and the use of the CoCM.

Australian breast surgeons and ultrasound usage: Have practices changed?

BACKGROUND: A recent survey of surgeon performed ultrasound usage was conducted amongst registered members of the Breast Surgeons of Australia and New Zealand Society (BreastSurgANZ) and was compared with a previous survey undertaken in 2010 to determine whether patterns of utilization had changed. METHODS: From July to September 2019, members of BreastSurgANZ were invited to complete an electronic online survey of personal usage of breast ultrasound focusing on ultrasound equipment access, use of office and intraoperative ultrasound, biopsy interventions and training expectations. RESULTS: There were 73 respondents to the survey with 45 (61.6%) members indicating access to ultrasound within their practices. Whilst current regular ultrasound usage (68.1%) was only slightly greater than in 2010 (66%), the proportion of respondents not performing any form of needle intervention had increased (62.5% compared to 53% in 2010) and with the proportion of surgeons currently performing >10 biopsies per month decreasing from 10% to only 5.56%. However the percentage of surgeons utilizing intraoperative ultrasound had notably increased since 2010 with 49.3% currently using ultrasound in the operating room compared with only 17% previously. The majority of respondents believed that breast ultrasound training should be conducted through BreastSurgANZ post fellowship training programs. CONCLUSION: The overall utilization of surgeon-performed ultrasound amongst BreastSurgANZ members has remained similar over the past 9 years with the performance of needle interventions declining slightly, but with the application of intraoperative ultrasound having increased. An ultrasound training curriculum as part of the BreastSurgANZ post fellowship training program is a necessary imperative.

Innovative applications of informatics for families, systems, and health: Introduction to the special issue.

The articles included in this special issue of Families, Systems, & Health on informatics represent distinct elements of health informatics relevant to the implementation and provision of clinical services. Informatics is the collection, analysis, and application of data for direct care decisions in health care and an interdisciplinary field that brings medicine together with computer, cognitive, and social sciences. We frame the contributions of the included articles within the framework of the Quadruple Aim for health care: better outcomes, lower costs, improved patient satisfaction, and improved work life of health care providers. The examples provided aim to show how health informatics provides opportunities to improve care delivered to patients at individual and system levels while both identifying and closing gaps in research addressing the management and use of information generated in the course of delivering health care. The articles in this special issue reflect the cutting edge of health care, research and technology, where there is as much risk as there is promise of delivering stability to our dynamic health care system. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Factors associated with successful implementation of telehealth abortion in 4 United States clinical practice settings.

OBJECTIVE: To overcome obstacles to delivering medication abortion services during the COVID-19 pandemic, clinics and providers implemented new medication abortion service models not requiring in-person care. This study identifies organizational factors that promoted successful implementation of telehealth and adoption of "no test" medication abortion protocols. STUDY DESIGN: We conducted 21 semi-structured, in-depth interviews with health care providers and clinic administrators implementing clinician-supported telehealth abortion during the COVID pandemic. We selected 15 clinical sites to represent 4 different practice settings: independent primary care practices, online medical services, specialty family planning clinics, and primary care clinics within multispecialty health systems. The Consolidated Framework for Implementation Research guided our thematic analysis. RESULTS: Successful implementation of telehealth abortion included access to formal and informal inter-organizational networks, including professional organizations and informal mentorship relationships with innovators in the field; organizational readiness for implementation, such as having clinic resources available for telehealth services like functional electronic health records and options for easy-to-use virtual patient-provider interactions; and motivated and effective clinic champions. CONCLUSIONS: In response to the need to offer remote clinical services, 4 different practice settings types leveraged key operational factors to facilitate successful implementation of telehealth abortion. Information from this study can inform implementation strategies to support the dissemination and adoption of this model. IMPLICATIONS: Examples of successfully implemented telehealth medication abortion services provide a framework that can be used to inform and implement similar patient-centered telehealth models in diverse practice settings.